Annals for Hospitalists - August 2022
Authors: Megan Mack, Matthew Luzum, David H. Wesorick
Journal: Annals of Internal Medicine (2022)

Web ExclusivesAugust 2022Annals for Hospitalists - August 2022FREEMegan Mack, MD*, Matthew Luzum, MD* and David H. Wesorick, MDMegan Mack, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (M.M., M.L., D.H.W.)Search for more papers by this author, Matthew Luzum, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (M.M., M.L., D.H.W.)Search for more papers by this author and David H. Wesorick, MDFrom Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (M.M., M.L., D.H.W.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202208160 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesImproving Medication Reconciliation in Hospitals—Jeffrey L. Schnipper, MD, MPHInaccurate medication reconciliation is a frequent cause of medication errors at hospital admission and discharge. This month's commentary explores the problem and its potential solutions.Highlights of Recent Articles From Annals of Internal MedicineAssociations of Atrial Fibrillation After Noncardiac Surgery With Stroke, Subsequent Arrythmia, and Death: A Cohort StudyAnn Intern Med. 2022;175:1065-1072. Published 26 July 2022. doi:10.7326/M22-0434This cohort study compared patients with a first occurrence of atrial fibrillation (AF) within 30 days of noncardiac surgery (postoperative) to those with first occurrence outside the postoperative time frame (nonoperative). Outcomes included transient ischemic attack (TIA) or ischemic stroke, subsequent atrial fibrillation, and death. Among the 4231 patients with occurrence of AF during the 13-year study period (2000–2013), 550 (13%) occurred in the postoperative period. After weighted analysis and adjustment for several comorbidities, no significant difference was seen in risk for TIA or ischemic stroke, cardiovascular-related death, or all-cause death between the postoperative and nonoperative groups after 5 years of follow-up. About 18% of patients with postoperative AF went on to have AF detected again within 1 year of the index episode. Anticoagulant prescription occurred in 49.4% of postoperative patients versus 61.7% of nonoperative patients.Key points for hospitalists include:The results of this study suggest that postoperative AF imparts a risk for TIA and stroke that is similar to nonoperative AF.Postoperative AF does not appear to always be a transient phenomenon—at least 18% of the patients with postoperative AF went on to have AF again in the next year (and this number is almost certainly an underestimate of the true recurrence rate).Together, these results suggest that more aggressive monitoring and/or treatment of postoperative AF may be warranted, although the optimal strategy (for example, close monitoring, anticoagulation, or rhythm control) is not yet clear.How Would You Treat This Patient With Pulmonary Embolism? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterAnn Intern Med. 2022;175:1160-1169. Published 9 August 2022. doi:10.7326/M22-0989In this case-based article, 2 experts discuss the role of advanced therapies and indefinite anticoagulation for a patient with intermediate-risk pulmonary embolism (that is, hemodynamically stable but with evidence of right heart strain).Key points for hospitalists include:For patients with intermediate-risk pulmonary embolism, the PEITHO (Pulmonary Embolism Thrombolysis) trial demonstrated that immediate systemic thrombolysis results in lower rates of hemodynamic decompensation than anticoagulation alone, but no reduction in mortality, and a significant increase in the risk for bleeding, including hemorrhagic stroke.Catheter-based therapies (including thrombolysis and embolectomy) seem to have benefits, with lower rates of bleeding than systemic thrombolysis, but evidence is limited.The best predictor of recurrent venous thromboembolism is whether the clot was provoked or not. One of the discussants recommends treating all unprovoked venous thromboembolism in patients with low risk for bleeding with indefinite anticoagulation (with the possible exception of women with a low HERDOO2 score), while limiting the duration of anticoagulation for those with a reversable provoking stimulus.Quantifying Individual-Level Inaccuracy in Glomerular Filtration Rate Estimation: A Cross-Sectional StudyAnn Intern Med. 2022;175:1073-1082. Published 5 July 2022. doi:10.7326/M22-0610This cross-sectional study compared estimated glomerular filtration rate (eGFR) (using serum creatinine concentration) with directly measured GFR (mGFR) (using urinary iothalamate and plasma iohexol clearance) in 3223 participants. Although population-level median differences were small, individual-level differences were large, resulting in substantial disagreement in staging of chronic kidney disease. For example, in patients with an eGFR of 60 mL/min/1.73 m2, 95% of the mGFRs ranged from 36 up to 87 mL/min/1.73 m2.Key points for hospitalists include:This study demonstrates that the eGFR calculated from the serum creatinine concentration can significantly overestimate or underestimate the mGFR in an individual patient.These inaccuracies can have important clinical consequences—an inaccurate eGFR may lead to a test or treatment being inappropriately withheld or administered.The authors suggest that direct GFR measurements should be made available to patients who need them and note that the modern mGFR technique is a safe and simple outpatient procedure.The Latest Highlights From Journal ClubWhat is the best practice for the periendoscopic management of anticoagulants and antiplatelet agents?ACG-CAG provided suggestions for periendoscopic management of anticoagulants and antiplateletsAnn Intern Med. 2022;175:JC74. doi:10.7326/J22-0041This guideline provides recommendations for management of these medications in patients undergoing endoscopy electively or for acute bleeding, but the evidence is largely of very low quality.How does cardiac computed tomography (CT) compare to invasive angiography in patients with intermediate-risk, stable chest pain?In intermediate-risk stable chest pain, treatment guided by initial CT vs. ICA did not differ for MACE at 3.5 yAnn Intern Med. 2022;175:JC76. doi:10.7326/J22-0047This European multicenter randomized controlled trial compared CT versus invasive coronary angiography as the first test in the evaluation strategy for patients with stable chest pain and intermediate risk for coronary disease and found no difference in rates of major adverse cardiovascular events at a median of 3.5 years.Does prone positioning improve outcomes in patients with COVID-19 requiring intensive care unit (ICU)–level respiratory support?In COVID-19 acute hypoxemic respiratory failure, awake prone positioning vs. the supine position reduces intubationsAnn Intern Med. 2022;175:JC81. doi:10.7326/J22-0050This systematic review of 10 randomized controlled trials concluded that prone positioning (vs. supine positioning) of ICU patients requiring noninvasive ventilation or high-flow nasal cannula resulted in lower rates of intubation but not lower mortality or shorter ICU length of stay.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (M.M., M.L., D.H.W.)Disclosures:Authors have reported no disclosures of interest. Forms can be viewed at http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-3315.* The authors contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Improving Medication Reconciliation in Hospitals Jeffrey L. Schnipper Metrics August 2022Volume 175, Issue 8Page: HO8 ePublished: 16 August 2022 Issue Published: August 2022 Copyright & PermissionsCopyright © 2022 by American College of Physicians. All Rights Reserved.Loading ...